Toxic Stress, Trauma, and
the Culture of Poverty
Darcy Lowell, MD
Founder and CEO, Child First, Inc.
Associate Clinical Professor
Yale University School of Medicine
Melissa Mendez, LCSW
Promising Starts Coordinator, Project LAUNCH
Child First Clinical Supervisor
New Britain
Overview of Session
• Toxic stress, ACEs, and early brain
development
• The power of nurturing relationships
• The culture of poverty
• Early identification
• Effective social-emotional interventions
• CT AIMH: Training and Endorsement
The Developing Brain
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Brain Development
 By 8 months of age, brain
synapses have increased from
50 to 1000 trillion:
700 synapses/second
 The child’s early experiences
actually build the architecture of
the brain - EPIGENETICS
 By 3 years, 80% of brain growth
is complete.
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But what happens in the face of
ADVERSITY, when early
experiences are threatening,
unpredictable, neglectful, or
abusive?
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TOXIC STRESS!
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Environmental Risks
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Extreme poverty
Domestic and community violence
Abuse and neglect
Parental mental health issues, especially depression
Substance abuse
Homelessness
Incarceration
Teen and single parenthood
Isolation and lack of social supports
Lack of education and illiteracy
Unemployment
Health and dental issues
Poor quality child care
Lack of basic needs:
food, clothing, heat, furniture
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Adverse Childhood
Experiences
ACEs
 HOUSEHOLD
 ABUSE
DYSFUNCTION
 Physical
 Emotional  Mental illness
 Domestic
 Sexual
violence
 NEGLECT
 Substance abuse
 Physical
 Incarceration
 Emotional
 Divorce
Brain Research:
Toxic Stress or ACEs
 Based on the most recent research about the
young, developing brain:
 High stress destroys brain
architecture.
 Leads to lifelong problems in:
 – Mental health
 – Development & learning
 – Physical health
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Biologic Effect of Profound Neglect
This 11 year old girl is
the size of a 4 year old.
She has markedly
reduced brain function
and growth.
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Behavioral Problems
 Incidence:
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1 risk = 7%
 8 + risks = 40%
 In Bridgeport:
 Of those children who
were high risk, 70%
screened positive for
emotional concerns
And It Does Not Just Go Away!
 Emotional or
behavioral problems
at age 3 years
50% psychiatric
diagnosis
by kindergarten
or 1st grade.
% Children with Social-Emotional Problems
Social-Emotional Problems by
Number of Risk Factors
0
1
2
3
4
Risks
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6+
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Power of Responsive
Nurturing
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Child Success
Language &
Cognitive
Development
Social –
Emotional
Health
Physical
Health
Nurturing
Relationships
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Who are the families
we want to reach?
How do we effectively engage
these families?
 We have to start by,
and be in consistent
practice of,
reflecting on our
values, beliefs and
assumptions about
ourselves and the
families we serve…
Values, Beliefs, and
Assumptions
 Values: How important something is.
 Beliefs: The ideas we accept as true.
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 Assumptions: Ideas based on our
past experiences.
Values, Beliefs, and Assumptions
 "Your beliefs become your thoughts,
 Your thoughts become your words,
 Your words become your actions,
 Your actions become your habits,
 Your habits become your values,
 Your values become your destiny."
 -Mahatma Ghandi
Families come to the work with
their own values, beliefs, and
assumptions
 Assumptions based on past experiences that
lead to current interactions:
 Can I trust you?
 Will you really help me?
 Could you hurt me?
 Do you ‘get’ me? (“you know how we are…”)
 Mental Model of Poverty handout
“Hidden Rules” Among Class
Groups
Poverty
Middle Class
Wealth
MONEY
To be used, spent To be managed
To be conserved,
invested
FOOD
Quantity: Is there
enough?
Quality: Did we
like it?
Presentation: Was
it presented well?
TIME
Present
Future
Traditions and
history
DESTINY
Fate
Choice
Noblesse oblige
MOTIVATIONS
Survival,
relationships,
entertainment
Work,
achievement
Financial, political,
social connections
“Hidden Rules” Video Clip
 http://www.youtube.com/watch?v=PYeWJlfu1ZA
 Hidden rules about discipline …
 Penance and forgiveness (pay a price/say you’re sorry)
 Change (what did you learn?)
Responding to Generational
Poverty Emotional/Cognitive
Mindset
 What is your tolerance level (1 (NO TOLERANCE) to 5
(HIGH TOLERANCE))
for a spouse/partner who:
1)Repeatedly gives money to a relative who does not
work?
2)Left bills unpaid to give money to a relative?
3)Quit job without having another because he/she
didn’t like the boss?
4)Kept a low-paying position because he/she didn’t
want to separate from close co-workers?
5)Allowed a relative or friend to stay move in for an
undetermined amount of time?
Societal and Family Systems
Highly mobile, nuclear
family
Clan network (family all
lives in same
neighborhood/close
proximity)
Extended family that
lives together and
shares resources
Friends sometimes take
place of extended family
Child may be used to high Child may have little
levels of activity in the
contact with people
home
outside of the family
Children may have little
contact with extended
family
“Drop ins” are the norm
Child experiences more
routines and structure in
their daily life
Child may eat or sleep in Child may be used to
more than one household sharing resources easily
(seen as “too passive”)
Child may be used to
having responsibilities in
the home/family
Why is it important to consider
these concepts?
 Enhances our working relationships with families
 Increases likelihood that families stay engaged
 10-25% of families in low-income communities choose
not to participate in early childhood home visiting
 20-67% of families in low-income communities fail to
fully complete early childhood home visiting services
 The relationship between the parent and the provider
is the most potent predictor for success of the
intervention.
Historical Trauma for Families
Living in Poverty
 Refers to cumulative of emotional and
psychological damage, exceeding over an
individual lifespan and across generations,
caused by significant group traumatic
experiences.
 "Historical trauma is defined... as a constellation
of characteristics associated with massive
cumulative group trauma across generations.”
Historical Trauma for Families
Living in Poverty
 “Historical trauma differs from other types of
trauma in that the traumatic event is shared by a
collective group of people who experience the
consequences of the event, as well as the fact
that the impact of the trauma is held personally
and can be transmitted over generations."
Early Identification
Interaction between
Brain Plasticity and Age
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Screening and Referral
 Identify children and families as early as possible
 Formal screening for risk and social-emotional
concerns
 Identification by
concerned providers
and caregivers
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Early Childhood Mental Health
Early Identification Opportunities
 Pediatric Primary Care Center
 Obstetrics (depression and substance use)
 Early Care and Education / Schools
 DCF
 DSS
 Birth to Three
 Home visiting programs
 WIC
 Family Resource Centers
Pediatric Primary Care
Center
 Pediatric Primary Care
Center at Bridgeport
Hospital
 1300 children
 47% + for emotional or
behavioral concerns
 62% + for environmental
risk
Screening Measures
 Emotional/Behavioral Development:
 Brief Infant-Toddler Social-Emotional Assessment
(BITSEA): under age 4 years
 Ages and Stages – Social-Emotional: 3 months to 6 years
 DECA – Infant/Toddler and Preschool
 Pediatric Symptom Checklist: over age 4 years
 Psychosocial Risk:
 Parent Questionnaire
 ACEs adult or child questionnaires (e.g., MIECHV DPH)
Parent Questionnaire:
Scoring Example
1. I am worried about my child’s development…………...
He/she is not learning as fast as I expected……………
YES NO
YES NO
Any Yes = 1
2. I am worried about my child’s behavior………………….
YES NO
I am worried that my child is not happy …….………… YES NO Any Yes = 1
3. I am employed or in an education/training program YES NO
My child’s other parent is employed or in an
3 Nos = 1
education/training program………………………………….
YES NO
I have completed high school or have a GED………… YES NO
4. I feel very worried, stressed or sad a lot of time……… YES NO
Sometimes I feel that life is just too hard to continue YES NO
*
Any Yes = 1
Parent Questionnaire:
Positive Screen
 3 or more points
 Yes in any one of the “red flag” questions – with a
star - is an automatic positive:
* # 4 – depression
* # 8 – domestic violence
* # 10 – substance abuse
 Any clinical concern, regardless of number of
points
Mental Health Services
Ecological Approach within an
Early Childhood System of Care
Community
Parental Challenges
Relationships
Child: Health &
Development
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Two-Pronged Approach
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2
 Decrease toxic
Facilitate the
psychosocial stress development of a
by connecting
responsive, nurturing
children and
parent-child
families to needed relationship that can
services and
protect the
supports.
developing brain.
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Target Population: Children
 Prenatal to 6 years
 Any problem that threatens
healthy development:
 Emotional/behavioral
 Developmental/learning
 Abuse and neglect
 Serve families with multiple
children
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Target Population: Parents
 Parents/caregivers (birth parents, foster
parents, relatives) with multiple challenges:
 Depression and other mental health problems
 Substance use
 Homelessness
 Domestic violence
 Child protective service
involvement
 Poverty
 Fathers and caregiving partners included
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Overview of Child First
Intervention
 Screening and community referrals
 Home-based intervention
 Engagement
 Comprehensive assessment
 Child and Family Plan of Care
 Targeted parent guidance
and Child-Parent Psychotherapy
 Mental health classroom consultation
 Connection to community-based services
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Parent-Child Intervention
 Intervention:
 Relationship-based, Trauma-informed
Child-Parent Psychotherapy (CPP)
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Focus on the meaning of the child’s behavior
 Parent guidance
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Developmental lens
 Promote executive
functioning
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Services and Supports
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Primary or specialty pediatric care
Early care and education
Birth to Three
Special education
Child mental health
Parenting groups
Family Resource Centers
Parent mentors and aides
Adult mental health
Substance abuse treatment
Adult health care
Legal aide
Domestic violence services
Transportation
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Housing / shelters
Job training
Computer training
Food stamps
Food banks
HUSKY
GED
Literacy
ESL
WIC
TANF
SSI
CSHCN
Clothing and furniture
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A Glimpse at How We
Help?
 First, we help by “holding” and supporting caregivers in
recognizing their “ghosts,” when it interferes with their
nurturing their children.
 Second, we help by supporting families in identifying their
“angels,” who have nurtured and held them in the past.
Other CT Service Models
 Child-Parent Psychotherapy – agency-based
 Circle of Security parenting groups
 Family-Based Recovery
 Minding the Baby
 Early Childhood Consultation Partnership
 Triple P
 Parent-Child Interaction Therapy
CT Association of
Infant Mental Health
Endorsement for Culturally
Sensitive, Relationship-focused
Services to Infants, Toddlers,
Parents, Other Caregivers and
Families.
CT-AIMH Endorsement
 Endorsement for Culturally Sensitive,
Relationship-focused Services to Infants,
Toddlers, Parents, Other Caregivers and Families
 http://www.ct-aimh.org/
 CT-AIMH Endorsement Coordinator
 Tanika Simpson, LCSW, IMH-E®
Thank you!
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 http://www.albertafamilywellness.org/resources/video/
how-brains-are-built-core-story-brain-development